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Case Endoftalmitis

Case Endoftalmitis

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Published by AynaSofi

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Published by: AynaSofi on Jun 24, 2012
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01/27/2015

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IDENTIFIKASINama : IrwanUsia : 53 tahun Jenis Kelamin : Laki-lakiPekerjaan : WiraswastaAgama : IslamAlamat : Dalam KotaKeluhan Umum : Mata kanan nyeri dan merah sejak 3 hari yang laluRPP : ± 1 Bulan yang lalu pasien operasi katarak mata kanan denganoperasi ….± 1 Minggu yang lalu mata kanan terdapat kotoran mata +berwarna kuning.± 3 Hari yang lalu mata kanan merah, silau +, berair -, gatal -,nyeri +, susah membuka mata kanan +, merah +, bintik putih -.Mata kiri merah -, sakit kepala -, trauma -, demam -, pasiensusah melihat jauh dikedua mata.RPD : - Riwayat Sinusitis --Riwayat trauma --Riwayat sakit gigi --Riwayat Kencing Manis -RPK : - Riwayat penyakit yang sama disangkal-Riwayat menggunakan kacamata STATUS GENERALIS Temp : afebris Pulse : 65 X / menitRR : 22 X / menit TD : 120/80 mmHg
 
STATUS OPHTALMOLOGICUSVOD : 1/300 PH( - ) VOS : 6/60 PH 6/30 TIOD : Tidak dilakukan TIOS : 15,5 mmHg BCVA : Tidak dinilaiKBM orthoforiaGBMPalpebra Edema sup et inf TenangKonjungtiva Hiperemis, secret +, kemosis - TenangKornea Infiltrat +, keruh +, FT -, Jernihpenggaungan -BMD Hipopion 2/3 BMD, sedang SedangIris Sulit dinilai Gambaran BaikPupil Sulit dinilai Bulat, Central dan ReflekCahaya +Lensa Sulit dinilai Keruh, Shadow Test+Segmen Posterior :RFOD Sulit dinilai RF +Papil Sulit dinilai Bulat, Central, TegasMakula Sulit dinilai RF +
-2-2
 
Retina Sulit dinilai Kontur Pembuluh DarahBaikDIAGNOSIS KERJAEndofthalmitis OD Post Operasi Katarak + Katarak Imatur OSDIAGNOSIS BANDING-Panofthalmitis-SellulitisPENATALAKSANAAN1.MRS2.Inform Consent3.Injeksi Subkonjungtiva Gentamisin4.Steroid 0,1 Intravitreal5.Asam mefenamat 3x5 00mg6.Kultur test KOH dan Gram7.Pro USG8.Pro episerasi9.Spooling RL + Povide iodine 0,5 %10.Pro ECCE + IOL OS11.Cek Lab + darahPROGNOSAQuo ad Vitam : BonamQuo ad Functional : Dubia

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